~ Excerpted from the April 2007 Issue of LymphLink
The process by which exceptions are obtained for exceeding the $1780 annual limit to physical and speech therapy and occupational therapy have been published. The following is a URL for California and other states covered by the NHIC Medicare Contractor. Medicare Part B Contractors have issued or will issue similar direction for their regions.
CMS has taken another step making it more difficult for Medicare "Beneficiaries" to receive lymphedema care according to current treatment guidelines. In 2006, physical treatment of lymphedema (ICD-9-CM diagnostic codes 457.0 postmastectomy LE and 457.1 other LE) was automatically excepted from the annual $1740 limit. This year the exception is only afforded if a second co-diagnosis is shown "that MIGHT cause medically necessary therapy services to qualify for the automatic process exception for each discipline separately". Both ICD-9's must be shown on the claim. "In most cases, the severity of the condition, comorbidities, or complexities will contribute to the necessity of services exceeding the cap, and these should be documented." The annual limit has been raised to $1780 for 2007. I would like to document any experiences relating to exceeding the limits, and how they were handled.
Congressmen Xavier Becerra (D-CA), Phil English (R-PA), Mike Ross (D-AR), Charles Pickering (R-MS) and Roy Blunt (R-MO), and Senator John Ensign (R-NV) and ten Co-sponsors introduced "The Medicare Access to Rehabilitation Services Act" (HR 748/S. 450) on January 31, 2007 that would completely repeal the cap on therapy services for Medicare beneficiaries. If Congress does not take action by January 1, 2008 , the therapy cap will again be imposed on Medicare-covered physical therapy, occupational therapy, and speech language pathology services. We need to take action NOW to ensure the cap does not go back into place thereby making the burdensome exception process unnecessary.
Medicare lymphedema treatment coverage gets worse each year. In March 2005 CMS changed their interpretation of the Social Security Act and the Code of Federal Regulations to limit provision of manual lymph drainage “incident to” a physician’s service to physical and occupational therapists. This specifically eliminated coverage of treatment by specially-qualified nurses, physicians, osteopaths, chiropractors and massage therapists thereby reducing the number of available trained therapists by some 30 percent. A number of lymphedema treatment clinics around the country have already been forced to close as a result of this policy change.
Last year’s Access to Physical Medicine and Rehabilitation Services Improvement Act of 2006 (S. 3963) introduced by Sen. Craig Thomas (R-WY), attempts to ensure that Medicare beneficiaries have better access to quality health care provided by state licensed or certified health care professionals. It is anticipated that Senator Thomas will re-introduce his bill in this session. The Coalition to Preserve Patient Access to Physical Medicine and Rehabilitation Services, of which the Lymphedema Stakeholders is a member, supports changing the CMS’s “incident to” rule.
And in March 2006 CMS re-coded the compression garments which are the mainstay of lymphedema treatment from “prosthetics” (the benefit category covering compression garments for lymphedema) to “surgical bandages” (a benefit category which is not covered in a home setting or in the absence of an open wound). This effectively denies the millions of lymphedema Medicare beneficiaries coverage of the treatment which they require every day for the rest of their lives. See the Jul-Sept 2006 LYMPHLink page 11 ff for details.
Please contact your Congressional representatives. Urge them to sponsor and support bills which will correct these limitations to access to proper lymphedema treatment. (See the Jul-Sept 2006 LYMPHLink page 24 for details.) Send me a copy of the letter you write. I will be in Washington in early May and will follow up on your letter, and leave an information package with your Congressional representative on your behalf. The package will include a proposed "Lymphedema Diagnosis and Treatment Cost Saving Bill" which will address all of these issues.
"LYMPHEDEMA TREATMENT IS GOOD BUSINESS AS WELL AS GOOD MEDICINE"
Robert Weiss, M.S.
Lymphedema Treatment Advocate